Special Exposure Cohort Petition U.S, Department of Health and Human Services

under tha Enargy Empioyass Occupational Cenlars for Disease Contra! and Prevention

Iiness Compensation Act . National Institute for Occupational Safety and’ Health
OMB Number: 0920-0639 Expires: 05/31/2007

Special Exposure Cohort Petition —-Form B Pag

Basis for Proposing that Records and information are Inadequate for Individual Dose —

Complete Section F.

Complete at least one of the following entries In this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than ane entry.

Fil yf We have atlached either documents or statements provided by affidavit that indicate that
radiation exposures and radiation doses potentially incurred by members of the proposed ciass,
thal relate to this petition, were not monitored, alther through persona! monitoring or through area
monitoring.

3 (Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate thet potential radiation exposures were not monitored.
OFFICE WoRKERS Dip NOT WEAR
6 WERE N Mon TORE oO UE
oveice Bo pse +

F.2 BR i! We have attached either documents or slatements provided by affidavit that indicate that
radiation monitaring records for members of the proposed class nave been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, sourcs term, or process
from the site where the employees worked.

(Atlach documents and/or affidavits lo the back of the petition form.)

Describe-as completely as possible, to the extent it might be unclear, how the atlached
documentation and/or affidavit(s) indicate that radiation monitoring records for members of the
proposed class have been los, allered illegally, or destroyed,

Teg‘ ta} u e NoT

= —o

Part F Is continued on thé following page.

Name or Social Security Number of First Petitioner:



,

Special Exposure Cohort Petition U.S. Department of Health and Human Services

See een onecrese Oceupational Contora for Dieesee Control and Prevention

_ | liness Compensation F National Institute for Gooupational Sefety and Health

4 : OME Number: 0820-0639 ‘Expires: 5/91/2007

€S Special Exposure Cohort Petition —Form B ppendix — Continuation Page
et Continuation Page — Photocopy and complete as necessa

SEC Petit ooo47 AESADAVIT
Dee /Eew [4 ony -TC
NePaetMenT oF ENERAT Kefeet Dated e426 [1997

APoLLi 2 oOnInG YRopee’ otLo OA.
3 WAL TéchaicaAL KEVoR
CON TA MIWA EPoRT OF Ai = STAVES

Pawe oF 1943 REFER. IT WAS DeveRmwWed A

PRSOR BoARDS AnD DRAW LINES CONSTRINED URANIUM

Leave RA seDeb 6 PG C.

hE APOLLO OF ee ByenUgwe ASD PLANT Botk Wap To

He CARG vim Yemourshep, Contr ed HEBR
D.So Go gure Bo Pal, P OADED oN)

GONDOLA CARS AND TAKEN Aull FoR CosTROLLED
OFTSVE DISPOSAL.

SWs own Kecorps KSENTIO 6 € Ri
ESID VAL OAS TAM
EKisve bh WHE: THE Cs. DEMO’

TL Recall ja WHE NGARS J9lz-63-64 wed
L wofkken jn THE Aecoutwe Department is NUMeEC
LIWcHWAS hocatTeD on THE SECND FlooR oF ThE

SMALL WHEE STORY BuwDWwe, THAT These was
CHemMcAL TésTwe LAB Geiow oR LARGE OFFICE,

f(x h TPT dei
3 a a i i
SOARS SEAS

a
Moon TwpCounty of Allegheny

hy Commission Expires Mar. 13, 2008}
—<

Attach to Form B if nacesgary 7

Name or Social Security Number of First Patitioner.

te



@5

* F

Special Exposure Cohort Patition U.S, Department of Health and Human Services
Occupational

under the Energy Employeos Centers for Disease Control end Prevention
illness Compensation as ¥ National Institute for Occupational Safety and Health

OMB Number 0920-0639 * Expires: 05/31/2007

Spacial Exposure Cohort Petition —Form 8 Append: — Continuation Page

Continuation Page — Photocopy and complete

SEC PetityN dsoon7
NUuMec AVOLLO Site

THE Counter PRoliFeERatinr) PAPERS
S No. Zz
TSRAELS NUCLEAR WERPANS

Tie Th8d Temhue Hoy ae HOLES By wiARNER D, FARR uve es fay

RECADAVIT

UTTes ST pes AIR FoRce CoynTeR PRoLFERAT oN CENER,
BLS CHENNAULE CIRCLE

DAAKWELL AF BASE AL 36 12.- C127

THE ARTICLE SANS Thar /00 lcs of SuuTont um
S

OE ARG COMTRANATED NUMEC APOLLO PLANT
Ny WA: COMM ISS] 0A) é Cs
TWIS 16 THE conceéedsuS of THE FACULTY AT THe

Unitép STATICS AiR WAR ColLéece-.

ag _ RECALL Thay GoveRsmeuT

AGENTS WERE INVESTICATIVIG oe
RapoActiyS MATERIALS WEA) WIRKED AT

THE Nouméc office Buiepiwe wo 1964

<<
NOTARIAL SEat

EOC Filnh ) frtpr& [MARYS APPLEGARTH, Notary Publio
ee ag Moon Twp., County of Allagheny
‘ i rT

Attach to Form B If naceser

Name or Soclal Security Number of First Patitior



.

Spacial Exposure Cohort Petition U.S, Department of Health and Human Services

eae Enea eamreex Petpet Centers for Diseasa Conirol and Prevention
Iiness Compansation Act F National Inslitute for Qocupalicna! Safety and Health

. OMB Number: 0920-0639 “Expires: 05/31/2007
Special Exposure Cohort Petition —Form B Appendix — Continuation Page

o6oY] AEFADAVIT.

é5 Numec fRorro Site
FI RADIOACTIVE INC DEAT oz] 14] \ab3
.
Ay TAS _waS A Wor
gZ223 N OT OF TRE NUmEeC OFF
ES tA fiPallo, PRL
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26 $ HE _APoL ny iE. S
5 NE Smo D THE AIR
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art
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a 8 CALDWELL ARE WWES Cicasin ShowS cee FALuour
ae PATTERN OF ComTAMWATION ©
= ar
~S DEFice WORKERS ON WoT WERK Dose Gances

Attach to Form B If necansary;

Name or Social Security Number of First Petiti



Continuation Page — Photocopy and complete as ne:

Special Exposure Cohort Petition U.S. Department of Health and Human Services
Centers tor Disease Control and Prevention

under the Energy Employees Ocaupational

iiingss Compensation Act - Nalionat Institute for Occupational Safety and Health
OMB Number: 0920-0633 " Expires; 05/31/2007

Special Exposure Cohort Potltion —Form B Appandix — Continuation Page

SEC Petr tin oost7 AFFADIIT

PeaLlo iar BOWING
___ CoS TAMWATED
ot CA AME in
Se Ly wv £ UR

wit

Gast Alani ine is
AY PeRwdS oVER “The TERRE

AHE of FICE WURKERS Not MenitoRG)) with

Dose BadGes oR AREA  MoatitoRwe +

Lik &

Zt LATER

CE Wi

NOTAQIAL Sal

[MARY J, APPLEGARTH, Notary Public:
TY Moon Twp., County of Allegheny

Ty Commission =xpmes Mar, 13, 2008

Name or Social Security Number of First Petitioner: =

Attach to Form-Bif ndcessary:. =. <i



97-20-06 Ali:o7 oy

Special Exposure Cohort Petition us. Deperorere Health and Human Services
under the Energy Employees Occupational aay Rohice ta avolend Prevention
Ilingss Compensation Act National Instilute for Occupational Safaty and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 2 of 7

ection B if you are a Survivor or represen’ a Survivor,

B.1 Name of Survivor:

MrJMrs./Ms. First Name Middle Initial Last Name
B.2 Social Security Number of Survivor:
B.3 Address of Survivor:

Steet Apt # P.O. Box

City Stats Zip Code
B.4 Telephone Number of Survivar: \ 3
B.S Email Address of Survivor:

B.6 —_—- Relationship to Employee: Q Spouse  Son/Daughter OG Parent
Q Grandparent Q Grandchild

5 you are a labor org:

C1 Nam “*

(BeFites.nts, First Name miugne HMM vast Name
C.2 Former Name of Employee (e.g., maiden name/legal name change/other):

Mr/Mrs/Ms. First Name Middle Initial Last Name
C.3 Social Security Number of Employee: a

3 C4 Adidleace af Eeaninuss (i hina
Ant# BLO Box

City Stale fait ip Voge
€.5 Telephone Number of Employ:
C.6 Email Address of Employee: : * |

C.7 Employment Information Related to Petition:
©.7a_ Employee Number (if known):

bes rr read |
C.7b Dates of Employme! Sta mitue

vis S902. = End 4
C7e EmployerName ({NUMEC JNucLEAR MATERIALS ¢ GQuiPmENT Cor?

C.7d Work Site Location: ”_ FLPOLLLO ; PA

C.7e Supervisor's Name (Decensen )
HAS A N)OSR CLAW
Go to Part &. 3 . + : \

Name or “er Number of First Petitioner: =

Zz SEc ooo]


. County of Al
Expires Mar. 13,

Moon Twp.
My Commission

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*

fh Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Enargy Employeaa Occupational Centers for Disease Control and Prevention
ness Compensation Act ‘ National Institute for Occupational Safety and Health
OMB Number: 0920-0639 ‘ Expires: 05/34/2007

Special Exposura Cohort Patition —Form B. Appendix — Continuation Paga
Continuation Page — Photocepy and complete as necessary.

EC Petits ooo]
NUANE C APpLLo Site 2

RadiATiIoN Mod iToRWE INSTRUMENTS

ACEADAVIT.

4 LYTOAG
RED Yous well Rote

USWWG BiohSSAY . AIR SamP Weir aracer

He Showed TRAT TRADITIONAL (ADICATORS
Wsene Not -ADEAATE Any DaveloiPeo New TM caus
To MONITOR WORKERS THAT WERE Ape QuaATe.

Le fE-GE

DAD Cepeda
vy?

a

MARY.1_ APP! FGARTH, Notary Public
Moon fwp., County of Allegheny
My Commission Expires Mar, 13; 2008

Attach to Form B if necessary:

Name or Social Security Number of First Petition.

f2 v



‘Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Canters for Disease Contra! and Prevention
WWness Compensation Act P National institute for Occupational Safely and Health

; OMB Number: 0920-0839 © Expires: 05/31/2007
Special Exposure Cohori Petition —Form 8 Appendix — Continuation Page

Continuation Page — Photocopy and complete as necessary.

Sec Petrws 6047 AFER DV
Numéec APou.Lo OFFICE BoLywe
DoS [METRY fanssS

m x ~ BA) 7. 3 : ¢
oy gERCE GIORRERS WERE Nef Martone
TH DUG Yr Pease NAL Moa TOR WIG. of TH RovGy
AREA MomToR Wwe. OFMCE woRKERS Bip wot

ly < cS A Any Tneke Ane ye —__
EP oRTS. on OEFICg WoRKERS THAT T
aM nite of,

7 file / iy Le

NOTARIAL SEAL ss
=i , Notary PUIG, =
—}-hoortep eaumpobttegieny
— My Commission Evpires Mar 13,9009.
Attach to Form-B if necessary) 6" oe

Narne or Social Security Number of First Petitione

12 v



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Brpeyees Occupalianal Centers for Disease Control ahd Prevention
Iiness Compensation Act National institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 05/31/2007

pecial Exposure Cohort Patition—Form 8 Page 4 0f7
Proposed Definition of Employce Class Covered by Petition — Complete Section E.

E.1 Name of DOE or AWE Facility:
E.2 Locations at the Facility relevant to this petition:
NUMEC Aplin office BuediNG
NwmMEeC APoLLo PaAsT
E.3 List job titles and/or job duties of employees included in the class. In addition, you can list by
name any Individuals other than petitioners identified on this form who you believe should be
included In this class:
ALL NUMEC of Pe EmMPiyce' RATING € cle! iS
ALL AUMEC APoLLd LAST EmPLoN GES

E.4 Employment Dates relevant te this petition:

stat AST end 1983
Stari End
Starl 02/14/1463 End URANIUM FIRE INCIDENT
E.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposuro incidents?; x Yes Q No

If yes, provide the date(s) of the Incident(s) and a complets description (atlach additional pages
ag necessary):

DATE Of WerpentT 18 92/14 11943

SSé ATIACHED  AEFADAVIT

Go to Part F.

Name or Social Security Number of First Pelitioner: _

4



Special Exposure Cohort Petition U4, Department of Health and Human Services

under the Energy Emplayees Occypational Centers for Disease Control and Prevention
lliness Compensation Act National Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B ge 3087

Labor Organization Informa omplete Section D ONLY if yo bor organizaiion,
D.1 Labor Organization Information:

Name of Organization

Position of Contact Person
D2 Name of Petition Representative:

D8 Address of Petition Representative:

Street Apt # P.O, Box

City State Zip Code
D4 Talephone Number of Petition Representative: d :
D.5 Email Address of Petition Representative:

D.6 ——- Perlod during which labor organization reprasented employees covered by this petition
(please altach documentation): Start End

D.7 — Identity of other labor cs a that may represent or have represented this class of
amplayees (if known):

Name or Social Security Number of Firat Petitioner: _



Special Exposure Cohort Petition U.S. Department of Health and Human Services|

under the Energy Employees Occupational Centers for Disease Control and Prevention
Wingss Compansation Act i National institula for Occupational Safety and Health

Fi ‘OMB Number: 0920-063¢ Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Appendix — Petitioner 2

Use of this form and Gleclosure of Social Security Number are voluntary. Failure to use this form or disclase
this number will not result in the danial of any right, benefit, or privilege to which you may be entitled:

—

Use this Appendix for Petitioner 2.

This appendix form is to be used as n2aeded. Petitioner 2, or his or her representative, should complete the
parts applicable to him or her.

Refer to the General Instructions on completing petilioner information for Parts A, B,orc.

Ifyou nead more space {ce provide additional information, use the continuation page provided at tho end of
the form and altach the completed continuation page(s) to Form B.

Except for signatures, please PRINT all information clearly and neatly on the form.

An Energy Employee (current or former), Starl at C
‘A Survivor (of a former Energy Employee), Start at B

If you are:

1 A Representative (of a current or former Energy Employee), Start at A

& Representative Informatian — Complete Section Aif you are authorized by an Employee or
Survivor(s) to petition on behalf of a class,

A4 Are you a contact person for an organization? C1 Yes (Go to A.2) Q Mo (Go to A.3)
A2 — Organization Information:

Name of Organization

Position of Contact Person
A Name of Petition Representative:

Me/Mrs.JMs, First Name Middle Initial Last Name

A4 Address:
Streat Apt # . P.O. Box
City State - Zip Code

AS Telephone Number; ( +
A6@ — Email Address:

A? Check the box at tefl to indicate you have ettached to the back of this farm written authorization to
petition by the survivor{s) or employee(s) indicated in Parts B or C of this form. An authorization
form for this purpose Is provided.

If you are representing a Survivor, go to Part B; if you are reprasenting an Employee, go to Part C.

Name or Social Security Number of First Petitioner: .



Special Exposure Cohort Petition
under the Enasgy Emaloyeas Occupationat
{ness Compensation Act

Special Exposure Cohort Petition — Form B

U.S. Department of Health and Human Services)
Centers for Disease Control and Prevention

Naticnal Insitute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Page 6 af 7

F.3 WWe have altached a report from a health physicist or other individual with expertise In
radiation dose reconstruction dacumenting the limitations of existing DOE or AWE records on
radiation exposures at the facility, as relevant to the petition. The report specifies the basis for
believing these documented limitations might prevent the completion of dose reconstructions tor
members of the class under 42 CFR Part B2 and related NIOSH technical implementation
guidelines.

(Attach report to the back of the patition form.)

|We have attached a scientific or technical report, issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuciear Regulatory
Commission, or the Defense Nuclear Facilities Safety Board, or published In a peer-reviewed
journal, that identifies dosimetry and related Information thal are unavailable {due to either a lack
of monitoring or the destruciian or less of records) for estimating the radiation doges of
employees covered by the petition.

F4

(Attach report te the back of the petition form.)

Go to Part G,
Signature of Persan(s) Submitting this Petition — Complete Section G.

G

All Pot#ieners should sian and date the petition. A maximum of three persons may, ign the petition.

Of {17
Signature ‘Date *
Signature Date
Signature Date

Notice: Any person who knowingly maxes any false statement, misrepresentation, concealment of
fact or any other act of fraud to obtain compensation as provided under EEOICPA or who
knowing’y accepts compensation ts whieh that person is nol entitled is subject to civil or
administrative remedies es well es felony criminal prosecution and may, under appropriate
criminal previsions, be punished by ¢ fine or imprisonment or beth, | affirm that the Information
provided on this form is accurate and tus.

SEC Patition

Office of Compensation Analysis and Support
NIOSH

4676 Columbla Parkway, MS-C-47
Cincinnati, OH 45226

Send this form to:

If there are additional petitioners, they must complete the Appendix Farms for additional petitioners.
The Appendix forms are located at the end of this document. .

i eee

roy type

NOTARIAL SEAL

MABY J. APPLEGABTH, Notary Public!

wp., County of Allegneny
Moon bats Expires Mat. 4, 201

Name or Social Security Number of First Petitioner;